The biochemical pattern defines MASLD phenotypes linked to distinct histology and prognosis.

BACKGROUND: MASLD can manifest as hepatocellular damage, which can result in mild elevation of aminotransferases. However, in some patients, MASLD presents with cholestatic pattern. OBJECTIVE: To assess the impact of the biochemical pattern on the natural course of MASLD, including liver damage in histology, the accuracy of non-invasive tests(NITs), and prognosis. METHODS: Multicenter study enrolling 2156 patients with biopsy-proven MASLD, who were classified based on their[ALT/ULN)]/[(ALP/ULN)] levels at the time of biopsy: (a) hepatocellular pattern(H), > 5; (b) mixed pattern(M),2-5; (c) cholestatic pattern(C), < 2. OUTCOMES: (a) histological evaluation of the single components of NAS, MASH, and fibrosis; (b) NITs and transient elastography assessing advanced fibrosis; (c) prognosis determined by the appearance of decompensated cirrhosis and death. RESULTS: Out of the 2156 patients, 22.9% exhibited the H-pattern, whilst 31.7% exhibited the C-pattern. Severe steatosis, ballooning, lobular inflammation, and MASH (56.4% H vs. 41.9% M vs. 31.9% C) were more common in H-pattern (p = 0.0001),whilst C-pattern was linked to cirrhosis (5.8% H vs. 5.6% M vs. 10.9% C; p = 0.0001). FIB-4(0.74(95% CI 0.69-0.79) vs. 0.83 (95% CI 0.80-0.85); p = 0.005) and Hepamet Fibrosis Score(0.77 (95% CI 0.69-0.85) vs. 0.84 (95% CI 0.80-0.87); p = 0.044)exhibited lower AUROCs in the H-pattern. The C-pattern[HR 2.37 (95% CI 1.12-5.02); p = 0.024], along with age, diabetes, and cirrhosis were independently associated with mortality. Most patients maintained their initial biochemical pattern during the second evaluation. CONCLUSIONS: The H-pattern exhibited greater necro-inflammation in the histology than the C-pattern, whereas the latter showed more cirrhosis. The accuracy of NITs in detecting fibrosis was decreased in H-pattern. The occurrence of decompensated events and mortality was predominant in C-pattern. Therefore, identifying MASLD phenotypes based on the biochemical presentation could be relevant for clinical practice.

GALLBLADDER POLYPS: CORRELATION AND AGREEMENT BETWEEN ULTRASONOGRAPHIC AND HISTOPATHOLOGICAL FINDINGS IN A POPULATION WITH HIGH INCIDENCE OF GALLBLADDER CANCER.

BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

Quantifying methyl tunneling induced (de)coherence of nitroxides in glassy ortho-terphenyl at low temperatures.

The low-temperature Hahn echo decay signal of the pyrroline-based nitroxide H-mNOHex in ortho-terphenyl (OTP) shows two contributions on distinct time scales. Tunneling of the nitroxide's methyl groups cause electron spin echo envelope modulation (ESEEM) on a faster time scale compared to the slower matrix-induced decoherence contribution arising from nuclear pair ESEEM. Here we introduce the methyl quantum rotor (MQR) model that describes tunneling ESEEM originating from multiple methyl rotors coupled to the same electron spin. By formulating the MQR model based on a rotation barrier distribution P(V3), we account for the different local environments in a glassy matrix. Using this framework, we determine the methyl groups' rotation barrier distribution from experimental Hahn echo decay/two-pulse ESEEM data by a non-linear fitting approach. The inferred distributions are in good agreement with density functional theory (DFT) calculations of the methyl groups' rotation barriers in the low-temperature regime where tunneling constitutes the dominant methyl proton exchange process. In addition to comparing our results with previous decoherence studies performed on the same spin system, we experimentally confirm the characteristic properties of methyl tunneling by demonstrating that P(V3) is magnetic field independent and predominantly temperature independent between 10 and 50 K. This confirms the assignment of the fast Hahn echo decay contribution to methyl tunneling, showcasing how pulsed EPR sequences can coherently probe this quantum phenomenon for commonly employed nitroxide spin-labels.

Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding.

BACKGROUND: A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE. PATIENTS AND METHODS: This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation. RESULTS: 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients. CONCLUSION: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.

Gallbladder polyps: correlation and agreement between ultrasonographic and histopathological findings in a population with high incidence of gallbladder cancer / Pólipos da vesícula biliar: correlação e concordância entre achados ultrassonográficos e histopatológicos em uma população com alta incidência de câncer de vesícula biliar

ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

Pharmaceutical care program for patients with chronic kidney disease in the community pharmacy: Detection of nephrotoxic drugs and dose adjustment. Viability study.

INTRODUCTION: Chronic kidney disease (CKD) is a major health problem. Early detection is the key to reducing morbidity and mortality, but it is difficult because it occurs without symptoms. Diagnosis of CKD is also important to avoid nephrotoxic drugs and to adjust the doses of other medications that may be affected. Pharmacies, due to their proximity to the population, frequency of patient visits, and knowledge of medication use are an ideal location for point-of-care diagnosis or CKD. OBJECTIVE: To detect and refer to the primary care physician patients with low estimated glomerular filtration rate (eGFR) who use nephrotoxic drugs or who may require a dose adjustment. METHODOLOGY: Pharmacy users over 60 years of age who agreed to participate were given a creatinine/eGFR test with a point-of-care meter. The eGFR was calculated and if it was less than 60 ml/min/1.73 m2, their medications were evaluated to identify nephrotoxic drugs or drugs that potentially required adjustment. If either were found, they were referred to their doctor for further management. RESULTS: 198 patients were recruited in 4 pharmacies, of which 87 (43.9%) had an eGFR less than 60 ml/min/1.73 m2. They were taking a total of 635 medications. Of these 635 medications, 50 (7.9%) were affected by kidney function. Dose adjustment was recommended in 31 and discontinuation in 19. The primary care doctor accepted the recommendations for 14 medications: dose adjustment for 6 and withdrawal in 8. This represents 2.3% of medications taken by patients with an eGFR less than 60 ml/min/1.73 m2. The 50 medications identified were taken by 29 patients (33.3% of the 87 with a low eGFR) and a change in treatment was generated in 9 patients, representing 4.6% of the total number of patients in the sample, and 10% of the patients with a low eGFR. CONCLUSION: Point-of-care testing for kidney function in a pharmacy setting is feasible and identifies a significant number of patients with eGFR under 60 ml/min/1.73 m2. It also allows for appropriate medication management recommendations in this patient group.

Dipolar pathways in multi-spin and multi-dimensional dipolar EPR spectroscopy.

Dipolar electron paramagnetic resonance (EPR) experiments, such as double electron-electron resonance (DEER), measure distributions of nanometer-scale distances between unpaired electrons, which provide valuable information for structural characterization of proteins and other macromolecular systems. We present an extension to our previously published general model based on dipolar pathways valid for multi-dimensional dipolar EPR experiments with more than two spin-1/2 labels. We examine the 4-pulse DEER and TRIER experiments in terms of dipolar pathways and show experimental results confirming the theoretical predictions. This extension to the dipolar pathways model allows the analysis of previously challenging datasets and the extraction of multivariate distance distributions.

Compactness regularization in the analysis of dipolar EPR spectroscopy data.

Dipolar electron paramagnetic resonance (EPR) experiments, such as double electron-electron resonance (DEER), measure distributions of nanometer-scale distances between paramagnetic centers, which are valuable for structural characterization of proteins and other macromolecular systems. One challenge in the least-squares fitting analysis of dipolar EPR data is the separation of the inter-molecular contribution (background) and the intra-molecular contribution. For noisy experimental traces of insufficient length, this separation is not unique, leading to identifiability problems for the background model parameters and the long-distance region of the intra-molecular distance distribution. Here, we introduce a regularization approach that mitigates this by including an additional penalty term in the objective function that is proportional to the variance of the distance distribution and thereby penalizes non-compact distributions. We examine the reliability of this approach statistically on a large set of synthetic data and illustrate it with an experimental example. The results show that the introduction of compactness can improve identifiability.

Neural networks in pulsed dipolar spectroscopy: A practical guide.

This is a methodological guide to the use of deep neural networks in the processing of pulsed dipolar spectroscopy (PDS) data encountered in structural biology, organic photovoltaics, photosynthesis research, and other domains featuring long-lived radical pairs and paramagnetic metal ions. PDS uses distance dependence of magnetic dipolar interactions; measuring a single well-defined distance is straightforward, but extracting distance distributions is a hard and mathematically ill-posed problem requiring careful regularisation and background fitting. Neural networks do this exceptionally well, but their "robust black box" reputation hides the complexity of their design and training - particularly when the training dataset is effectively infinite. The objective of this paper is to give insight into training against simulated databases, to discuss network architecture choices, to describe options for handling DEER (double electron-electron resonance) and RIDME (relaxation-induced dipolar modulation enhancement) experiments, and to provide a practical data processing flowchart.

Consulta en servicio de urgencia y reingreso hospitalario después de una cirugía bariátrica primaria / Emergency department visit and Hospital Readmission after Primary Bariatric Surgery

Resumen Introducción: Las consultas en el servicio de urgencia (CU) y el reingreso (RI) hospitalario después de una cirugía bariátrica (CB) son importantes indicadores de calidad y seguridad. Sin embargo, existe escasa información de estos indicadores en nuestro medio nacional. En este trabajo analizamos las CU y RI de pacientes sometidos a una CB primaria en un centro universitario de alto volumen, y buscamos variables asociadas a estos indicadores. Materiales y Método: Estudio observacional retrospectivo que incluyó a todos los pacientes sometidos a bypass gástrico (BPG) o gastrectomía en manga (GM) laparoscópica primaria realizados de forma consecutiva en nuestra institución durante el período 2006-2007 y 2012-2013. Utilizando nuestros registros clínicos y base de seguimiento prospectivo, identificamos aquellos pacientes con CU o RI en nuestro hospital durante los primeros 30 días después del alta. Resultados: Se incluyeron 1.146 CB primarias, 53% (n = 613) fueron BPG y 47% (n = 533) GM. Un 8,03% (n = 92) de los pacientes tuvo al menos una CU y un 3,7% (n = 42) un RI. Las variables independientes asociadas tanto a CU como RI fueron el tiempo operatorio e índice de masa corporal (IMC) preoperatorio. No se encontró asociación estadística, en el periodo estudiado, para el tipo de CB realizada con la CU ni con el RI. Conclusión: Existe una baja proporción de pacientes que requieren CU y RI posterior a la CB, lo que demuestra la seguridad de estas intervenciones.

Introduction: Emergency department visits (EDV) and hospital readmission (HR) after bariatric surgery (BS) are important indicators of quality and safety in surgery, however there is little information on their characteristics in our national environment. Aim: In this work we analyze EDV and HR in patients undergoing a primary BS in a high-volume university center, and identify variables that could be associated with these indicators. Materials and Method: A retrospective observational study where we identified all patients undergoing Roux-in-Y gastric bypass (RYGBP) or primary laparoscopic sleeve gastrectomy (SG) performed consecutively at our institution during the period 2006-2007 and 2012-2013. Using our clinical records and prospective follow-up database, we identify those patients with EDV and/or HR in our hospital during the first 30 days after discharge. Results: 1146 primary BS were included, of these 53% (n = 613) were RYGBP and 47% (n = 533) SG. 8,03% (n = 92) of the patients had at least one EDV, of these 3,7% (n = 42) had an HR. The independent variables associated with EDV and HR were the operative time and preoperative body mass index (BMI). No statistical association was found, in the period studied, for the type of BS performed with EDV or HR. Conclusion: There is a low proportion of patients who require EDV and HR after BS, which demonstrates the safety of these interventions.

Dipolar pathways in dipolar EPR spectroscopy.

Dipolar electron paramagnetic resonance (EPR) experiments such as double electron-electron resonance (DEER) measure distributions of nanometer-scale distances between unpaired electrons, which provide valuable information for structural characterization of proteins and other macromolecular systems. To determine these distributions from the experimental signal, it is critical to employ an accurate model of the signal. For dilute samples of doubly spin-labeled molecules, the signal is a product of an intramolecular and an intermolecular contribution. We present a general model based on dipolar pathways valid for dipolar EPR experiments with spin-1/2 labels. Our results show that the intramolecular contribution consists of a sum and the intermolecular contribution consists of a product over individual dipolar pathway contributions. We examine several commonly used dipolar EPR experiments in terms of dipolar pathways and show experimental results confirming the theoretical predictions. This multi-pathway model makes it possible to analyze a wide range of dipolar EPR experiments within a single theoretical framework.

Decompensation in Advanced Nonalcoholic Fatty Liver Disease May Occur at Lower Hepatic Venous Pressure Gradient Levels Than in Patients With Viral Disease.

BACKGROUND & AIMS: Portal hypertension is the strongest predictor of hepatic decompensation and death in patients with cirrhosis. However, its discriminatory accuracy in patients with nonalcoholic fatty liver disease (NAFLD) has been challenged because hepatic vein catheterization may not reflect the real portal vein pressure as accurately as in patients with other etiologies. We aimed to evaluate the relationship between hepatic venous pressure gradient (HVPG) and presence of portal hypertension-related decompensation in patients with advanced NAFLD (aNAFLD). METHODS: Multicenter cross-sectional study included 548 patients with aNAFLD and 444 with advanced RNA-positive hepatitis C (aHCV) who had detailed portal hypertension evaluation (HVPG measurement, gastroscopy, and abdominal imaging). We examined the relationship between etiology, HVPG, and decompensation by logistic regression models. We also compared the proportions of compensated/decompensated patients at different HVPG levels. RESULTS: Both cohorts, aNAFLD and aHVC, had similar baseline age, gender, Child-Pugh score, and Model for End-Stage Liver Disease score. Median HVPG was lower in the aNAFLD cohort (13 vs 15 mmHg) despite similar liver function and higher rates of decompensation in aNAFLD group (32% vs 25%; P = .019) than in the aHCV group. For any of the HVPG cutoff analyzed (<10, 10-12, or 12 mmHg) the prevalence of decompensation was higher in the aNAFLD group than in the aHCV group. CONCLUSIONS: Patients with aNAFLD have higher prevalence of portal hypertension-related decompensation at any value of HVPG as compared with aHCV patients. Longitudinal studies aiming to identify HVPG thresholds able to predict decompensation and long-term outcomes in aNAFLD population are strongly needed.

Emotional and psychological implications for healthcare professionals in disasters or mass casualties: A systematic review.

AIM: To synthesize and describe the emotional and psychological implications for healthcare professionals who provided care in a mass casualty incident or disaster. BACKGROUND: The experience of healthcare providers immersed in the actual uncertainty of an ongoing disaster is real, challenging, complex and strongly connected with emotions. Identifying these implications for healthcare professionals is essential for developing strategies to help these professionals deliver high-quality care. EVALUATION: A systematic review was conducted in PubMed, CINAHL, Scopus, Nursing & Allied Health Database and PsycINFO using published data until February 2021 and following the PRISMA guidelines. KEY ISSUES: Nineteen articles were included. Factors associated with negative psychological implications were identified and different strategies have been synthesized to prevent or reduce them when caring for the victims of a disaster. CONCLUSIONS: Feelings of sadness, helplessness, fear and blockage, among others, were identified as common reactions among nurses and other healthcare professionals dealing in mass casualties or disasters. These reactions may lead to post-traumatic disorder, turning professionals into hidden victims. IMPLICATIONS FOR NURSING MANAGEMENT: Organizations, senior charge nurses and other health service managers need to foster resilience and flexibility among their workforce to improve self-care during a disaster, as well as ensure policies to address a lack of emotional preparedness among their personnel. Some strategies to consider include cognitive behavioural therapy, psychoeducation or meditation.

New beginnings in post graduate medical education. Latin American Medical Education Leaders Forum / Nuevos comienzos en la educación médica de postgrado. Foro Latinoamericano de Líderes en Educación Médica

Introduction: The consequences of the Covid-19 epidemic have been catastrophic for Latin America in 2021. This study explores experiences, lessons learned, and practice changes during this critical time in post-graduate medical education in Latin America. Me-thods: A panel of 53 post-graduate medical education leaders from 8 Latin American countries and Canada was invited to participate in the 2021 Latin American Medical Education Leaders Forum to share their experiences, lessons learned, and main educational practice changes given the Covid-19 pandemic scenario. Participants were selected following a snowball technique with the goal of obtaining a diverse group of experts. Small group discussions were conducted by bilingual facilitators based on a semi-structured questionnaire. The plenary session with the main conclusions of each group was recorded and fully transcribed for a thematic analysis using a framework methods approach. Results: Participants ́ profiles included 13 experienced clinician-educators, 19 program directors, and 23 deans or organizational representatives. Seven specific themes emerged. They followed a pattern that went from an initial emotional reaction of surprise to a complex collective response. The responses highlighted the value of adaptability, the application of new digital skills, a renovated residents' protagonism, the strengthening of humanism in medicine, the openness of new perspectives in wellness, and finally, an unresolved challenge of assessment in medical education in a virtual post-pandemic scenario. Conclusion: A diverse panel of medical educators from Latin America and Canada identified changes triggered by the Covid-19 pandemic that could transform postgraduate medical education in the region.

Introducción: la pandemia de Covid-19 ha tenido consecuencias catastróficas para América Latina en el año 2021. Este estudio explora las experiencias, lecciones aprendidas y nuevas prácticas surgidas durante este crítico período en la educación médica de postgrado en América Latina. Métodos: un panel de 53 líderes de 8 países de América Latina y Canadá fue invitado a participar en el Foro Latinoame-ricano de Líderes en Educación Médica 2021 para compartir sus experiencias, lecciones aprendidas y cambios de prácticas educativas en el escenario de pandemia. Los participantes fueron seleccionados mediante la técnica de bola de nieve con el objetivo de obtener un grupo diverso de expertos. El Foro incluyó discusiones de pequeños grupos conducidos por facilitadores bilingües basadas en un cuestionario semiestructurado. La sesión plenaria con las principales conclusiones de los grupos fue grabada y transcrita para el análisis temático posterior utilizando la metodología de marco analítico. Resultados: el perfil de participantes incluyó 13 experimentados edu-cadores, 19 directores de programa y 23 decanos o representantes institucionales. Siete tópicos emergieron durante la discusión. Ellos siguieron un patrón que transitó desde una reacción emocional de sorpresa por la pandemia hasta una respuesta colectiva compleja. Las respuestas enfatizaron el valor de la adaptabilidad, la aplicación de nuevas habilidades digitales, un renovado protagonismo de los residentes, el fortalecimiento del humanismo en medicina, la apertura a nuevas perspectivas de bienestar y, finalmente, un desafío no resuelto respecto de la evaluación en educación médica en escenarios de pandemia. Conclusión: un panel diverso de educadores médicos latinoamericanos y canadienses identificó cambios claves gatillados por la pandemia de Covid-19 que pueden transformar la educación médica de postgrado en la región.

Benchmark Test and Guidelines for DEER/PELDOR Experiments on Nitroxide-Labeled Biomolecules.

Distance distribution information obtained by pulsed dipolar EPR spectroscopy provides an important contribution to many studies in structural biology. Increasingly, such information is used in integrative structural modeling, where it delivers unique restraints on the width of conformational ensembles. In order to ensure reliability of the structural models and of biological conclusions, we herein define quality standards for sample preparation and characterization, for measurements of distributed dipole-dipole couplings between paramagnetic labels, for conversion of the primary time-domain data into distance distributions, for interpreting these distributions, and for reporting results. These guidelines are substantiated by a multi-laboratory benchmark study and by analysis of data sets with known distance distribution ground truth. The study and the guidelines focus on proteins labeled with nitroxides and on double electron-electron resonance (DEER aka PELDOR) measurements and provide suggestions on how to proceed analogously in other cases.

Regularized dynamical decoupling noise spectroscopy - a decoherence descriptor for radicals in glassy matrices.

Decoherence arises from a fluctuating spin environment, captured by its noise spectrum S(ω). Dynamical decoupling (DD) with n π pulses extends the dephasing time if the associated filter function attenuates S(ω). Inversely, DD noise spectroscopy (DDNS) reconstructs S(ω) from DD data by approximating the filters pass band by a δ-function. This restricts application to qubit-like spin systems with inherently long dephasing times and/or many applicable pulses. We introduce regularized DDNS to lift this limitation and thereby infer S(ω) from DD traces of paramagnetic centers in glassy o-terphenyl and water-glycerol matrices recorded with n ≤ 5. For nitroxide radicals at low temperatures, we utilize deuteration to identify distinct matrix- and spin center-induced spectral features. The former extends up to a matrix-specific cut-off frequency and characterizes nuclear spin diffusion. We demonstrate that rotational tunneling of intramolecular methyl groups drives the latter process, whereas at elevated temperatures S(ω) reflects the classical methyl group reorientation. Ultimately, S(ω) visualizes and quantifies variations in the electron spins couplings and thus reports on the underlying spin dynamics as a powerful decoherence descriptor.

Intentional mass-casualty incident simulation-based training: A qualitative study into nursing students' perceptions and experiences.

BACKGROUND: The number of intentional mass casualty incidents (IMCI) has increased in recent years, and hemorrhage control is one of the important life-saving techniques used in these events. OBJECTIVE: The objective of this study is to understand the perceptions and experiences of nursing students subjected to a simulated intentional mass-casualty incident after receiving a training action within their curriculum, focused on how to respond to active threats and bleeding control. DESIGN: A qualitative phenomenological study on nursing students (n = 74) enrolled in the Nursing Care for Critical Patients course, facing a simulated IMCI in November 2019. DATA SOURCES: A total of 7 focus groups were performed, containing 8 to 12 participants each. FINDINGS: Participants reported a feeling of vulnerability and fear of an IMCI occurrence. Based on this context, the participants reported not knowing how to react to this type of situation, which is why training activities such as this one is seen as a way of improving participants' self-protection and safety. Likewise, a simulated IMCI is considered useful for any citizen and as a training exercise for life-saving techniques, such as hemorrhage control. CONCLUSIONS: Training on the subject of hemorrhage control using a simulated IMCI setting could increase self-efficacy and self-control, as well as reducing feelings of fear and vulnerability. Such training intervention could be primary prevention measures of an IMCI as well as a sustainable way to train knowledge-transmitting instructors.

Mild AST elevation as an early sign of COVID-19 severity in a multicenter Madrid cohort.

INTRODUCTION: liver enzyme elevation has been reported in SARS-CoV-2 disease (COVID-19) in heterogeneous cohorts, mainly from China. Comprehensive reports from other countries are needed. In this study, we dissect the pattern, evolution, and predictive value of such abnormalities in a cohort from Madrid, Spain. METHODS: a retrospective study with a prospective 14-day follow-up of 373 patients with confirmed COVID-19 in five Madrid hospitals, including 50 outpatients. A COVID-19 severe course was defined as the need for mechanical ventilation. RESULTS: a total of 33.1 % of hospitalized patients showed baseline AST elevation and 28.5 % showed ALT elevation, compared with 12 % and 8 % of outpatients (p ≤ 0.001). Baseline AST, ALT and GGT levels correlated with LDH and C-reactive protein (CRP) levels (r ≤ 0.598, p < 0.005). AST elevation was associated with other severity markers such as male sex, lymphopenia, and pneumonia on X-Ray (p < 0.05 for all). ALP and bilirubin levels were rarely increased. Patients with elevated baseline AST showed a progressive normalization of this enzyme and an increase in ALT and GGT levels. Patients with normal baseline AST showed a flattened evolution pattern with levels within the range. Patients with a severe course of COVID-19 more frequently showed elevated baseline AST than those with a milder evolution (54.2 % vs. 25.4 %, p < 0.001). Age, AST and CRP were independent risk factors for a severe course of COVID-19. CONCLUSION: mild liver enzyme elevation is associated with COVID-19 severity. Baseline AST is an independent predictor of severe COVID-19 course, and tends to normalize over time. ALT and GGT show a late elevation.

Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review.

AIMS AND OBJECTIVES: The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use. BACKGROUND: Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery. DESIGN AND METHODS: An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines. RESULTS: A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement. CONCLUSIONS: Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use. RELEVANCE TO CLINICAL PRACTICE: Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.

Definite and indeterminate nonalcoholic steatohepatitis share similar clinical features and prognosis: A longitudinal study of 1893 biopsy-proven nonalcoholic fatty liver disease subjects.

BACKGROUND AND AIM: Histological score systems may not fully capture the essential nonalcoholic steatohepatitis (NASH) features, which is one of the leading causes of screening failure in clinical trials. We assessed the NASH distribution and its components across the fibrosis stages and their impact on the prognosis and their relationship with the concept of metabolic-associated fatty liver disease (MAFLD). METHODS: Spanish multicenter study including 1893 biopsy-proven nonalcoholic fatty liver disease (NAFLD) patients from HEPAmet registry. NASH was diagnosed by NAS score ≥4 (including steatosis, ballooning and lobular inflammation) and fibrosis by Kleiner score. The presence of MAFLD was determined. Progression to cirrhosis, first episode of decompensated cirrhosis and death were collected during the follow-up (4.7 ± 3.8 years). RESULTS: Fibrosis was F0 34.3% (649/1893), F1 27% (511/1893), F2 16.5% (312/1893), F3 15% (284/1893) and F4 7.2% (137/1893). NASH diagnosis 51.9% (982/1893), and its individual components (severe steatosis, ballooning and lobular inflammation), increased from F0 (33.6%) to F2 (68.6%), and decreased significantly in F4 patients (51.8%) (P = .0001). More than 70% of non-NASH patients showed some inflammatory activity (ballooning or lobular inflammation), showing a similar MAFLD rate than NASH (96.2% [945/982] vs. 95.2% [535/562]) and significantly higher than nonalcoholic fatty liver (NAFL) subjects (89.1% [311/349]) (P < .0001). Progression to cirrhosis was similar between NASH (9.5% [51/539]) and indeterminate NASH (7.9% [25/316]), and higher than steatosis (5% [14/263]) (logRank 8.417; P = .015). Death and decompensated cirrhosis were similar between these. CONCLUSIONS: The prevalence of steatohepatitis decreased in advanced liver disease. However, most of these patients showed some inflammatory activity histologically and had metabolic disturbances. These findings should be considered in clinical trials whose main aim is to prevent cirrhosis progression and complications, liver transplant and death.